Family Information Notebook (FIN) - Vanderbilt Kennedy Center

13
MEDICAL POWER OF ATTORNEY
I, _____________________________________________________________, do give
(Name of Parent or Guardian)
permission for the following people to make decisions regarding medical treatment for
my child, ______________________________________________, should the need arise.
(Child’s Name)
Power of Attorney is given for emergency medical and dental care, including anesthesia
when it is needed. This consent is effective from this date and remains active until the
date indicated here, unless otherwise revoked:
Name:
Address:
Phone:
Beeper:
Name:
Address:
Phone:
Beeper:
Name:
Address:
Phone:
Beeper:
NOTARY
Parent name:
__________________
(Date)
Parent signature:
Notary name:
Date
Notary signature:
seal here Date
© Junior League Family Resource Center 2005